Infertility and Assisted Conception Flashcards
how long are patients waiting for treatment?
less than 12 months
how many cycles of IVF/ICSI are offered where there is reasonable expectation of a live birth?
three
what are the common indications for ART?
endometriosis male factor infertility tubal disease unexplained reasons ovulatory disorder multiple male and female factors
other than the common ones, what are the other indications for assisted conception treatment?
fertility preservation in cancer, transgender patients and social reasons
treatment to avoid transmission of blood born viruses between patients
pre-implantation diagnosis of inherited disorders
treatment of single parents or same sex couples
treatment with surrogacy when absent / abnormal uterus
before treatment begins, what lifestyle factors must be checked / put in place?
alcohol = females limit to 4 units per week
weight = between 19-29
smoking = stop
folic acid = 0.4mg/day preconception-12 weeks gestation
rubella = immunise
smears = up to ate
occupational factors = avoid hazards
drugs = prescribed, OTC and recreational
screen for blood born viruses
assess ovarian reserve = antral follicle count or AMH
what assisted conception treatments are available?
donor insemination intra-uterine insemination (IUI) in vitro fertilisation (IVF) intra-cytoplasmic sperm injection (ICSI) fertility preservation surrogacy
when is intra uterine insemination indicated?
sexual problems
same sex relationships
discordant BBV
abandoned IVF
how is IUI carried out?
can be in natural / stimulated cycle
prepared semen inserted into uterine cavity around time of ovulation
what are the indications for IVF?
unexplained (>2 years durations) pelvic disease (endometriosis, tubal disease, fibroids) anovulatory infertility (after failed ovulation induction) failed intra-uterine insemination (after 6 cycles)
what are the two phases of ovarian folliculogenesis?
tonic phase (65 days) = primary and secondary follicles to antral follicles
growth phase (20 days) = antral follicles 3-5mm to pre-ovulatory follicle (20nm), dependent on gonadotrophin
*in a stimulated cycle, gonadotropins during early follicular phase result in synchronised growth of all follicles (approx 1.5mm per day)
what is the first stage in IVF treatment?
down-regulation
- synthetic gonadotrophin releasing hormone analogue or agonist
- switches off egg production
- allows precise timing of oocyte recover by using HCG trigger
- side effects = hot flushes and mood swings, nasal irritation and headaches
- scan performed
what is the second stage in IVF treatment?
ovarian stimulation
- gonadotrophin hormone containing either synthetic or urinary gonadotrophins (FSH +/- LH)
- can be self administered sc injection
- causes follicular development
what does HCG injection cause?
mimics LH causing resumption of meiosis in oocyte, 36 hours before oocyte recovery
what is the third stage of IVF and what are the risks of this?
oocyte collection
risk = bleeding, pelvic infection, failure to obtain oocytes
what is the job of the embryologists in maturing human egg?
search through follicular fluid
identify eggs and surrounding mass of cells
collect them into cell culture medium
incubate at 37oc
what is the fourth stage in IVF?
sperm collection
abstinence for 72 hours beforehand, produced in mens room in ward or at home (within 1 hour)
assessed for volume, density (number of sperm), motility (what proportion are moving), progression (how well they move)
what is the fifth stage of IVF?
fertilisation
*two pronuclei, male and female genetic information, approx 60% of eggs fertilise normally
what is the sixth stage of IVF?
embryo transfer (usually on day 5 after fertilisation)
- normally transfer 1 (max 3)
- luteal support: progesterone suppositories for 2 weeks
how long after oocyte recovery is a pregnancy test performed?
16 days
what are the indications for ICSI?
severe male factor infertility
previous failed fertilisation with IVF
preimplantation genetic diagnosis
what will be required for ICSI in the case of azoospermia?
surgical sperm aspiration
*can be extracted from epididymis (if obstructive) or testicular tissue (non-obstructive)
what is the process of ICSI?
each egg is stripped
sperm immobilised
single sperm injected
incubate at 37oc overnight
what is the biggest complication of ART?
ovarian hyper-stimulation syndrome
what are the symptoms of ovarian hyper-stimulation syndrome?
mild = bloating, mild abdo pain, ovarian size <8cm
moderate = moderate abdo pain, nausea + vomiting, ascites on US, ovarian size 8-12cm
severe = clinical ascites, oliguria, haematocrit >0.45, hyponatraemia, hypo-osmolality, hyperkalaemia, hypoproteinaemia, ovarian size >12cm
critical = tense ascites/large hydrothorax, haematocrit >0.55, high WBC, oliguria/anuria, thromboembolism, ARDS
how can ovarian hyper-stimulation syndrome be prevented?
low dose protocols
use of antagonist for suppression
how can OHSS be treated before embryo transfer?
elective freeze
single embryo transfer
how can OHSS be treated after embryo transfer?
monitor with scans and bloods
reduce risk of thrombosis (fluids, TED stockings and fragmin)
analgesia
hospital admission if requires IV fluids / more intense monitoring/paracentesis
how have multiple pregnancy rates been decreased in IVF?
the move to blastocyst transfer
improved cryopreservation
increase in single embryo transfer
currently, what % of babies born from ART are multiple pregnancies?
10%
what is the biggest complication of ART?
ectopic pregnancies
*incidence increased 2-3 fold with IVF
what are other problems associated with ART?
no eggs retrieved (v uncommon) surgical risks of oocyte retrieval (bleeding, infection) surgical risks of surgical sperm aspiration (haematoma, infection) failed fertilisation problems in early pregnancy increase risk in on-going pregnancy psychological problems failed treatment
what body regulates and licences all ART activities?
human fertilisation and embryo authority (HFEA)
- regulate all treatment and research
- consider welfare of child
- rights of people seeking treatment to appropriate care
- respect for human life at all stages of development
what is the current success rate for IVF?
35%
